Notice to Driver and Safety Sensitive Applicants

hoffmann.dennis11

Notice to Driver and Safety Sensitive Applicants

930 Tamalpais AvenueSan Rafael, California 94901-3325Whistlestop.orgNotice to Driver and Safety Sensitive ApplicantsWhistlestop Wheels conducts drug and alcohol testing in compliance with Federal MotorCarrier Safety Regulations of the Department of Transportation parts 40, 382, 383, 390-397, 399 Subchapter B, Chapter 3, Title 49 of the Code of Federal Regulation. What thismeans is that all Drivers and Safety Sensitive employees and applicants for those positionsare subject to:1. Pre-employment drug testing – All applicants must pass a pre-employment drug testbefore they can be considered for employment.2. Random Testing – All safety sensitive employees are subject to random testing fordrug use and alcohol abuse. 50% are tested for drugs annually, and 10% are testedfor alcohol abuse annually.3. Post Accident Testing – Any safety sensitive employee having involvement in anaccident wherein someone is killed, injured to the point of requiring immediateemergency medical attention, or a vehicle can not continue under its own power willbe tested for drugs and alcohol.4. Reasonable Suspicion Testing – Any safety sensitive employee who exhibits signsof intoxication will be tested for drugs, alcohol or both.5. Return to Work Testing – Any safety sensitive employee who leaves work for anextended period of time (more than 90 days) must take a drug test prior to returningto their safety sensitive position.Upon Employment, you will be required to submit to a finger print criminal recordbackground check. Conviction of certain sexual felonies will disqualify you for continuedemployment with Whistlestop Wheels.To drive a Whistlestop bus you must be reasonably physically fit. You should have fullrange of motion. You should be able to lift 50 pounds. You will be required to pass a DOTphysical examination as part of obtaining your commercial license.I, the undersigned, have read and understand the above requirements.Applicant Signature:Date:


An Equal Opportunity EmployerPLEASE PRINT930 Tamalpais Avenue, San Rafael, CA 94901APPLICATION FOR EMPLOYMENTDateLast Name First Name MiddleMAILING ADDRESSNo. & Street City State ZipTELEPHONE NUMBERBusiness PhoneHome PhonePermanent Address (if different from present address)No. & Street City State Zip(No PO Boxes)EMPLOYMENT DESIREDPosition applying for: ______________________________________________Are you applying for:Regular full-time work?……………………….……….. Yes NoRegular part-time work?………………………… … Yes NoWhat days and hours are you available for work? ______________________________________If hired, on what date can you start work? __________Salary desired: _____________________________________________PERSONAL INFORMATIONHave you ever applied to or worked for Whistlestop before?……. Yes NoIf yes, when? ___________________________________Do you have any friends or relatives working for Whistlestop?…… Yes NoIf yes, state name(s) and relationship:NameNameRelationshipRelationshipWhy are you applying for work at Whistlestop?If hired, would you have a reliable means of transportation to and from work?…... Yes No1


Are you at least 18 years old? (If under 18, hire is subject to verification that you are ofminimum legal age.)……….. Yes NoIf hired, can you present evidence of your U.S. citizenship or proof of your legal right to liveand work in this country?….. Yes NoAre you able to perform the essential functions of the job for which you are applying, eitherwith or without reasonable accommodation?…….. Yes NoIf no, describe the functions that cannot be performed.(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligibleapplicants/employees to perform essential functions. Hire may be subject to passing a medical examination, skilland agility tests.)Have you ever been convicted of a criminal offense (felony or misdemeanor)? Yes No(Convictions for marijuana-related offenses that are more than two years old need not be listed.)If yes, state nature of the crime(s), when and where convicted, and disposition of the case.(Note: A conviction will not necessarily exclude you from consideration.)Are you currently employed?………………………. Yes NoIf so, may we contact your current employer?…. Yes NoEDUCATION, TRAINING, AND EXPERIENCESchool Name No. of years Did you Degreeand Address Completed Graduate? or DiplomaHigh ___________________________ ___ Yes No ________School NameAddressCity State ZipCollege/ ___________________________ ___ Yes No ________University NameAddressCity State Zip2


Vocational/ _____________________________ ___ Yes No _______Business NameAddressCity State ZipHealth Care ______________________________ ___ Yes No ________Training NameAddressCity State ZipMany of our customers (clients) do not speak English. Do you speak, write or understand any foreignlanguages?……………… Yes NoIf yes, which languages(s)? ________________________________________Do you have any other experience, training, qualifications, or skills which you feel make you especially suited forwork at Whistlestop?…… Yes NoIf so, please explain:Answer the following questions if you are applying for a professional position:Are you licensed/certified for the job applied for?………. Yes NoName of license/certification: __________________________________Issuing state: ___License/certification number___________________________________Has your license/certification ever been revoked or suspended?…… Yes NoIf yes, state reason(s), date of revocation or suspension, and date of reinstatement.EMPLOYMENT HISTORYList below all present and past employment starting with your most recent employer (last five years issufficient). Account for all periods of unemployment. You must complete this section even if attaching aresume.Name of EmployerType of Business3Telephone No.Your Supervisor's NameAddress & Street City State ZipDates of Employment:Weekly Pay:From To Starting EndingYour Position and DutiesReason for LeavingMay we contact this employer for a reference?……….. Yes No


Name of EmployerType of BusinessTelephone No.Your Supervisor's NameAddress & Street City State ZipDates of Employment:Weekly Pay:From To Starting EndingYour Position and DutiesReason for LeavingMay we contact this employer for a reference?………. Yes NoName of EmployerType of BusinessTelephone No.Your Supervisor's NameAddress & Street City State ZipDates of Employment:Weekly Pay:From To Starting EndingYour Position and DutiesReason for LeavingMay we contact this employer for a reference?………. Yes NoName of EmployerType of BusinessTelephone No.Your Supervisor's NameAddress & Street City State ZipDates of Employment:Weekly Pay:From To Starting EndingYour Position and DutiesReason for LeavingMay we contact this employer for a reference?………. Yes NoName of EmployerType of BusinessTelephone No.Your Supervisor's NameAddress & Street City State ZipDates of Employment:Weekly Pay:From To Starting EndingYour Position and DutiesReason for LeavingMay we contact this employer for a reference?………. Yes NoNote: Attach additional page(s) if necessary.MILITARY SERVICEHave you obtained any special skills or abilities as the result of service in the military?… Yes NoIf so, describe:4


PROFESSIONAL REFERENCESList below three persons not related to you who have knowledge of your work performance within the last threeyears.First Name Last Name Telephone No.Address & Street City State ZipOccupationNo. of Years AcquaintedFirst Name Last Name Telephone No.Address & Street City State ZipOccupationNo. of Years AcquaintedFirst Name Last Name Telephone No.Address & Street City State ZipOccupationNo. of Years AcquaintedPLEASE READ CAREFULLY AND SIGN BELOWI hereby certify that I have not knowingly withheld any information that might adversely affect mychances for employment and that the answers given by me are true and correct to the best of myknowledge. I further certify that I, the undersigned applicant, have personally completed thisapplication. I understand that any omission or misstatement of material fact on this applicationor on any document used to secure employment shall be grounds for rejection of this application or forimmediate discharge if I am employed, regardless of the time elapsed before discovery.I hereby authorize Whistlestop to thoroughly investigate my references, work record,education and other matters related to my suitability for employment and, further, authorize the referencesI have listed to disclose to the agency any and all letters, reports and other information related to my workrecords, without giving me prior notice of such disclosure. In addition, I hereby release theagency, my former employers and all other persons, corporations, partnerships and associationsfrom any and all claims, demands or liabilities arising out of or in any way related to suchinvestigation or disclosure.I understand that nothing contained in the, or conveyed during any interview which maybe granted or during my employment, if hired, is intended to create an employment contract betweenme and the agency. In addition, I understand and agree that if I am employed, my employment is (At-will)for no definite or determinable period and may be terminated at any time, with or without priornotice, at the option of either myself or the agency, and that no promises or representationscontrary to the foregoing are binding on the agency unless made in writing and signed by me andthe agency’s designated representative.Upon employment, you will be required to submit to a finger print criminal record background checkand may be required again in three years. Conviction of certain sexual felonies will disqualify you forcontinued employment with Whistlestop.I, the undersigned, have read and understand the above requirements.DateApplicant’s Signature5


DISCLOSUREDISCLOSURE - Must be a clear and conspicuous written disclosure to the consumerbefore the report is obtained, in a document that consists solely of the disclosure. Samplelanguage is shown below:As part of our hiring background and investigation, we may obtain consumer reports or preparean investigative consumer report. The investigative consumer report may consist of contactingall listed prior employers to verify your employment history. It may also include, but not belimited to, credit information reports, criminal history reports and driving history records. Underthe provisions of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before wecan seek such reports, we must have your written permission to obtain the information. You havethe right, upon written request, to a complete and accurate disclosure of the nature and scope ofthe investigation. You are also entitled to a copy of your Rights Under the Fair Credit ReportingAct.


AUTHORIZATION TO RELEASE INFORMATIONI,Last Name First Name Middle NameCurrent AddressAddresses for the Past Seven Years: (include street, city, state, zip code)Dates Lived HereDates of Residence:Date of Birth Other Names Used (including maiden name) Years UsedSocial Security Number Driver's License # StateEmail address (may be used for official correspondence)do hereby authorize verification of all information in my employment application from all sources of employment,education, motor vehicle, financial history, criminal history, personal character, and worker's compensation recordsin accordance with ADA, labor and wage records, etc. or any part thereof, and authorize any duly authorized agentof IntelliCorp Records, Inc to obtain, whether the said records are public or private, and including those whichmay be deemed to be privileged or confidential in nature and I release all persons from liability on account of suchdisclosures. Information appearing on this Authorization will be used exclusively by IntelliCorp Records, Inc foridentification purposes and for the release information which will be considered in determining any suitability foremployment. I certify that I have made true, correct, and complete answers and statements on my employmentapplication, any supplements to it and in any interview in the knowledge that they will be relied upon in consideringmy application for employment. I agree to provide additional information that may be requested to process myemployment application. I authorize without reservation, any party or agency contacted by IntelliCorp Records,Inc to furnish the above-mentioned information. This authorization is valid during the course of my employment tothe extent permitted by law.**I hereby do _______do not_________ authorize you to contact my current employer for Employment andReference Verifications(This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors orreferences in the Employment/Reference Section of your application.)


I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request the nature andsubstance of all information in its files on me at the time of my request, including sources of information, and therecipients of any reports on me which IntelliCorp Records, Inc has previously furnished within the two year periodpreceding my request.I understand and agree that any omission, false statement, misleading statement, or answer made by me on myapplication or any supplements to it and in any interviews will be sufficient grounds for rejection of employmentand my discharge after employment.Printed Name Applicant Signature DateOklahoma, or Minnesota resident and would like to request a copy of your Consumer Report or InvestigativeConsumer Report, please check the box. This report may include character and reputation informationobtained through personal interviews.DISCLAIMER: THIS FORM IS NOT MEANT TO PROVIDE LEGAL ADVICE OF ANY KIND.LEGAL ADVICE SHOULD BE SOUGHT FROM YOUR ATTORNEY. WE MAKE NO CLAIMS,PROMISES OR GUARANTEES ABOUT THE ACCURACY, COMPLETENESS, OR ADEQUACYOF THE INFORMATION CONTAINED HEREIN. WE MAKE NO WARRANTY THAT THISFORM IS APPROPRIATE FOR YOUR PARTICULAR NEEDS.


REQUEST/CONSENT FOR INFORMAnON FROM PREVIOUS EMPLOYER ON ALCOHOL & CONTROLLED SUBSTANCES TESTINGSECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEEI, (Print Name)First, M.I., Last Social Security Numberhereby authorize that:Previous Employer:Street:City, State, Zip:Telephone:Fax No.may release and forward information requested by Section 2 (below) ofthis document concerning my Alcohol and Controlled Substances Testingrecords to:Prospective Employer:Attention:Marin Senior Coordinating Council Inc. (Whistlestop Wheels)Jon GaffueyStreet: 930 Tamalpais Avenue Telephone:City, State, Zip: San Rafael, CA 94901 Fax No. 415-456-1581Applicant SignatureDateThis is in compliance with §382.405(f) and (h), which state:two years, which are maintained by the driver's previous employers under(f) Records shall be made available to a subsequent employer upon receipt ofa §382.401(b)(l(i) through (iii). As well as other violations ofDOT agency drugwritten request from a driver. Disclosure by that subsequent employer isand alcohol testing regulations and, with respect to any employee who violatedpermitted only as expressly authorized by the terms ofthe driver's request. DOT drug and alcohol regulation, documentation ofthe employee's successful(h) An employer shall release information regarding driver's records as directed completion ofDOT return-to-duty requirements (including follow up drug tests.by the specific, written consent ofthe driver authorizing release ofthe (c) The information in paragraph (b) ofthis section must be obtained andinformation to an identified person. Release ofsuch information by the person reviewed by the employer no later than 14 calendar days after the first time areceiving the information is permitted only in accordance with the terms ofthe driver performs safety-sensitive functions for an employer.employee's consent. (d) The prospective employer must provide to each ofthe driver's employers§382.413(a)(b)(c)(0)(f) further state:within the two preceding years the driver's specific written authorization ft)r(a) An employer may obtain, pursuant to a driver's written consent, any ofthe release ofthe information in paragraph (b)information concerning the driver which is maintained under this part by fhe (e) The release ofany information under this part may take the form ofdriver's previous employers.personal interviews, telephone interviews, letters, or any other method of(b)IAn employer shall obtain, pursuant to a driver's consent, information on obtaining information that ensures confidentiality. Each employer must maintainthe driver's alcohol tests with a concentration result of0.04 or greater positive a written, confidential record with respect to each past employer contacted.controlled substances test results, and refusals to be tested, within the preceding ISECTION 2: . TO BE COMPLETED BY PREVIOUS EMPLOYERCOMPLETE THIS SECTION AS IT PERTAINS TO PART 382. SEE SEC. 382.413(b), ABOVE. YES NOI. Has this person ever tested positive for a controlled substance in the last two years? D D2. Has this person ever had an alcohol test with a Breath Alcohol Concentration 0.04 or greater in the last two years? D D3. Has this person ever refused a required test for drugs or alcohol in the last two years? D DIfYES to any ofthe above questions, please give the SAP's (Substance Abuse Professional) name, address and phone number tor further reference.Name:Street:City, State, Zip:Section 2 Completed by (Signature):Date:SECTION 3: TO BE COMPLETED BY PROSPECTIVE EMPLOYERThis form was (check one) D Faxed to previous employer. DComplete below when information is obtained.Information received from:Mailed. Date:Recorded by: Method: D Fax D MailD P!lOneDate: D Personal Interview


REQUEST/CONSENT FOR INFORMAnON FROM PREVIOUS EMPLOYER ON ALCOHOL & CONTROLLED SUBSTANCES TESTINGSECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEEI, (Print Name)First, M.I., Last Social Security Numberhereby authorize that:Previous Employer:Street:City, State, Zip:Telephone:Fax No.may release and forward information requested by Section 2 (below) ofthis document concerning my Alcohol and Controlled Substances Testingrecords to:Prospective Employer:Attention:Marin Senior Coordinating Council Inc. (Whistlestop Wheels)Jon GaffueyStreet: 930 Tamalpais Avenue Telephone:City, State, Zip: San Rafael, CA 94901 Fax No. 415-456-1581Applicant SignatureDateThis is in compliance with §382.405(f) and (h), which state:two years, which are maintained by the driver's previous employers under(f) Records shall be made available to a subsequent employer upon receipt ofa §382.401(b)(l(i) through (iii). As well as other violations ofDOT agency drugwritten request from a driver. Disclosure by that subsequent employer isand alcohol testing regulations and, with respect to any employee who violatedpermitted only as expressly authorized by the terms ofthe driver's request. DOT drug and alcohol regulation, documentation ofthe employee's successful(h) An employer shall release information regarding driver's records as directed completion ofDOT return-to-duty requirements (including follow up drug tests.by the specific, written consent ofthe driver authorizing release ofthe (c) The information in paragraph (b) ofthis section must be obtained andinformation to an identified person. Release ofsuch information by the person reviewed by the employer no later than 14 calendar days after the first time areceiving the information is permitted only in accordance with the terms ofthe driver performs safety-sensitive functions for an employer.employee's consent. (d) The prospective employer must provide to each ofthe driver's employers§382.413(a)(b)(c)(0)(f) further state:within the two preceding years the driver's specific written authorization ft)r(a) An employer may obtain, pursuant to a driver's written consent, any ofthe release ofthe information in paragraph (b)information concerning the driver which is maintained under this part by fhe (e) The release ofany information under this part may take the form ofdriver's previous employers.personal interviews, telephone interviews, letters, or any other method of(b)IAn employer shall obtain, pursuant to a driver's consent, information on obtaining information that ensures confidentiality. Each employer must maintainthe driver's alcohol tests with a concentration result of0.04 or greater positive a written, confidential record with respect to each past employer contacted.controlled substances test results, and refusals to be tested, within the preceding ISECTION 2: . TO BE COMPLETED BY PREVIOUS EMPLOYERCOMPLETE THIS SECTION AS IT PERTAINS TO PART 382. SEE SEC. 382.413(b), ABOVE. YES NOI. Has this person ever tested positive for a controlled substance in the last two years? D D2. Has this person ever had an alcohol test with a Breath Alcohol Concentration 0.04 or greater in the last two years? D D3. Has this person ever refused a required test for drugs or alcohol in the last two years? D DIfYES to any ofthe above questions, please give the SAP's (Substance Abuse Professional) name, address and phone number tor further reference.Name:Street:City, State, Zip:Section 2 Completed by (Signature):Date:SECTION 3: TO BE COMPLETED BY PROSPECTIVE EMPLOYERThis form was (check one) D Faxed to previous employer. DComplete below when information is obtained.Information received from:Mailed. Date:Recorded by: Method: D Fax D MailD P!lOneDate: D Personal Interview


REQUEST/CONSENT FOR INFORMAnON FROM PREVIOUS EMPLOYER ON ALCOHOL & CONTROLLED SUBSTANCES TESTINGSECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEEI, (Print Name)First, M.I., Last Social Security Numberhereby authorize that:Previous Employer:Street:City, State, Zip:Telephone:Fax No.may release and forward information requested by Section 2 (below) ofthis document concerning my Alcohol and Controlled Substances Testingrecords to:Prospective Employer:Attention:Marin Senior Coordinating Council Inc. (Whistlestop Wheels)Jon GaffueyStreet: 930 Tamalpais Avenue Telephone:City, State, Zip: San Rafael, CA 94901 Fax No. 415-456-1581Applicant SignatureDateThis is in compliance with §382.405(f) and (h), which state:two years, which are maintained by the driver's previous employers under(f) Records shall be made available to a subsequent employer upon receipt ofa §382.401(b)(l(i) through (iii). As well as other violations ofDOT agency drugwritten request from a driver. Disclosure by that subsequent employer isand alcohol testing regulations and, with respect to any employee who violatedpermitted only as expressly authorized by the terms ofthe driver's request. DOT drug and alcohol regulation, documentation ofthe employee's successful(h) An employer shall release information regarding driver's records as directed completion ofDOT return-to-duty requirements (including follow up drug tests.by the specific, written consent ofthe driver authorizing release ofthe (c) The information in paragraph (b) ofthis section must be obtained andinformation to an identified person. Release ofsuch information by the person reviewed by the employer no later than 14 calendar days after the first time areceiving the information is permitted only in accordance with the terms ofthe driver performs safety-sensitive functions for an employer.employee's consent. (d) The prospective employer must provide to each ofthe driver's employers§382.413(a)(b)(c)(0)(f) further state:within the two preceding years the driver's specific written authorization ft)r(a) An employer may obtain, pursuant to a driver's written consent, any ofthe release ofthe information in paragraph (b)information concerning the driver which is maintained under this part by fhe (e) The release ofany information under this part may take the form ofdriver's previous employers.personal interviews, telephone interviews, letters, or any other method of(b)IAn employer shall obtain, pursuant to a driver's consent, information on obtaining information that ensures confidentiality. Each employer must maintainthe driver's alcohol tests with a concentration result of0.04 or greater positive a written, confidential record with respect to each past employer contacted.controlled substances test results, and refusals to be tested, within the preceding ISECTION 2: . TO BE COMPLETED BY PREVIOUS EMPLOYERCOMPLETE THIS SECTION AS IT PERTAINS TO PART 382. SEE SEC. 382.413(b), ABOVE. YES NOI. Has this person ever tested positive for a controlled substance in the last two years? D D2. Has this person ever had an alcohol test with a Breath Alcohol Concentration 0.04 or greater in the last two years? D D3. Has this person ever refused a required test for drugs or alcohol in the last two years? D DIfYES to any ofthe above questions, please give the SAP's (Substance Abuse Professional) name, address and phone number tor further reference.Name:Street:City, State, Zip:Section 2 Completed by (Signature):Date:SECTION 3: TO BE COMPLETED BY PROSPECTIVE EMPLOYERThis form was (check one) D Faxed to previous employer. DComplete below when information is obtained.Information received from:Mailed. Date:Recorded by: Method: D Fax D MailD P!lOneDate: D Personal Interview